Debates about harm reduction follow the same pattern: relentless hostility, proof that it works, then more relentless hostility. This is the ‘drug problem’ problem

No matter how impressive the evidence of benefits, or how weak the evidence of serious side effects or how badly a strategy is needed, new harm reduction strategies are always greeted the same way: with relentless hostility.

Debates about harm reduction always follow the same pattern. Hysterical fears are confidently asserted as if proven beyond doubt while potential benefits, often based on considerable research and experience, are dismissed or ignored.

Many harm reduction interventions are eventually approved, usually too little and too late, and then turn out to be far more successful than had been hoped. Fierce opposition to the intervention usually continues long after evaluation has shown it to have great benefits and insignificant negatives. Then the opposition takes many years to slowly die away.

Harm reduction is usually associated with illicit drugs. But long before there was harm reduction for illicit drugs, there was already harm reduction for alcohol. Alcohol policy wonks in the 1970s used to speak of “making the world safe for drunks”. They knew that, like the poor, some hopelessly intoxicated people in public places would always be with us. The idea behind this slogan was, for example, separating drunken pedestrians from speeding traffic. Of course energetic efforts to reduce the frequency and severity of public drunkenness still continued.

In 1970, the Victorian parliament made the wearing of seat belts compulsory for drivers and front-seat passengers, the first such legislation in the world. Concerns about the high proportion of road crashes due to drunk driving and the difficulties of reducing such deaths prompted the introduction of this legislation. Seat belt critics argued that drivers would inevitably compensate for their increased safety by just driving faster and more recklessly. Studies showed that the net reduction in crashes, deaths, serious injuries and financial savings was huge.

As a young doctor, I quickly became converted to public health harm reduction interventions when shown a scale model of a new wing being constructed at the Alfred Hospital in Melbourne in 1971. The wing had been designed before seat belt legislation had been approved and was being built after seat belts were compulsory. Many beds initially reserved for treating people with complex fractured skulls had now been made redundant and were now available for treating other conditions. I remember the vigorous debate about the introduction of car seat belts.

Much like other harm reduction debates, the conflict continued after seat belts had been introduced, eventually dying away long after studies showed clearly the huge savings in deaths, injuries, hospital beds and health care costs.

The idea of risk compensation runs through every debate about harm reduction. The notion is that all of us accept a certain amount of risk. If our exposure to risk is decreased, the risk compensation hypothesis suggests that we then increase our risky behaviour to return our overall risk level back to an equilibrium position. Sometimes we actually do increase an unwanted and risky behavior because of a reduced risk exposure. For this reason, it is very important that harm reduction policies are always carefully evaluated after being introduced to make sure that the benefits exceed the negatives.

In the 1980s, my colleagues and I were desperate to establish a pilot needle syringe program. Our concern was that Australia was at risk of severe health, social and economic costs from spread of HIV among and from people who inject drugs ending up with a possible generalized epidemic. This concern was widely shared. But all sorts of groundless concerns were raised about needle syringe programs. Could we prove that this wouldn’t send the wrong message? Would drug use start earlier, become more frequent or last longer? Would the sky fall in?

My colleagues and I had to resort to civil disobedience – starting the pilot program ourselves – to ensure that a needle and syringe policy was implemented before a generalised HIV epidemic occurred. An independent study commissioned by the commonwealth department of health a quarter century later found that between 2000 and 2009, needle syringe programs in Australia had cost $243m but had prevented an estimated 32,050 HIV and 96,667 hepatitis C new infections and saved the economy between $2.48 and $5.85bn.

In the 1999, my colleagues and I again had to resort to civil disobedience to ensure that a medically supervised injecting centre was established in Kings Cross – we started an illegal medically supervised injecting centre in the Wayside Chapel.

That year, 1,116 young Australians died of a heroin overdose with 10% of these deaths occurring within 2km of Kings Cross. A dozen independent evaluations of the centre have been strongly positive and found nothing more than insignificant negatives. When he retired, NSW premier Bob Carr said that establishing the centre was one of his ten proudest achievements. Yet fifteen years later, it’s still the only Drug Consumption Room (DCR) in the country.

When we suggest that future DCRs should adapt to the changed patterns of drug use and be able to accommodate people who inhale ice, the criticism starts all over again.

We follow the same pattern with all the other debates about harm reduction including medicinal cannabis, pill testing, regulation of recreational cannabis, and e-cigarettes: evidence of benefits is minimised while harms and risks are exaggerated.

A senate committee in 1977 referred to the “drug problem problem”, meaning the lamentable quality of the debate about drug policy. Almost four decades later the drug problem problem and adversarial politics still get in the way of rational discussions about effective ways of reducing the harm from drugs and drug policy.